Implant Treatment in Esthetic Zone

INTRODUCTION

Achieving and maintaining optimal gingival esthetics around anterior implants is a demanding task. Inspite of the high success rates achieved with osseointegrated implants, high rate of gingival recession has been reported in anterior implant cases.¹ The predictability of aesthetics depends on the loss of tissue present at the initiation of treatment. The greater the bone and soft tissue loss, the more difficult it is to produce an ideal aesthetic result. Esthetic success depends on a number of factors ranging from relationship between hard and soft tissues, soft tissue biotype and root position in the alveolar bone to three-dimensional implant position and angulation, and the contour of the abutment and the provisional restoration.²

CASE REPORT

A male patient aged 18 years, reported with missing maxillary central incisors to the private practice for the replacement of his missing teeth [Figure 1]. Patient gave a history of trauma and loss of teeth 8 months back. A thorough clinical examination was done followed by radiographic evaluations by taking intraoral periapical (IOPA) radiographs and orthopantomographs (OPG). Maxillary and mandibular diagnostic impressions were made to obtain diagnostic casts. A thorough medical history was taken to rule out any systemic disease. All the available prosthetic treatment options were explained. Bone mapping was done for the implant site and it revealed the labiopalatal cortical bone width to be 5.9 mm and mesiodistal length as 6.8 mm. It was planned to place an implant of size 4.0 mm × 11 mm in the left and right central incisor region. The patient was prepared for the surgery and local infiltration was given at site where implant was to be placed. Incision was given to elevate the mucoperiosteal flap. The osteotomy was started with a pilot drill initially and gradually, enlarged in width till 4.0mm and till a depth of 11 mm. During the osteotomy preparation paralleling pins were used to evaluate the parallelism of the implant site being prepared [Figure 2]. Once the osteotomy site was prepared, implant fixtures of dimension 4.0 mm × 11 mm were placed (Dentium NR Line,Korea ) and checked for parallelism radiographically [Figure 3,4]. Cover screws was placed and flap was sutured back with 4.0 non-resorbable silk sutures [Figure 5,6]. Postoperative instructions were given along with prescription of analgesics and antibiotics. Follow-up was done after every 2 weeks. After 4 months, the second stage surgery was done in the central incisor region and a gingival formers of size 4.5 mm × 3 mm were placed. After 1 week the suture placed were removed and gingival formers were replaced by closed tray impression posts which were customized with flowable composite according to soft tissue architecture[Figure 7]. A customized closed tray impression was made with elastomeric impression material. Zirconia crowns were fabricated and cemented. Chair-side postoperative IOPA radiograph was taken to assess the complete seating of implant abutment on implant fixture. The patient’s occlusion was checked and the implant retained fixed prosthesis was evaluated for esthetics and phonetics [Figure 8].

DISCUSSION

Replacement of missing maxillary anterior teeth with dental implants is a viable treatment option. Dental implant-supported prosthesis highly beneficial over crown and bridge or removable prosthesis. Dental implants help in retaining residual bone, ease of oral hygiene maintenance, and non-involvement of adjacent teeth.³ Certain clinical parameters play an important role in order to provide successful and aesthetic treatment. This is specifically true in the anterior maxilla, where the teeth and their supporting structures are readily visible.⁴ Successful implant treatment to replace missing teeth in the anterior maxilla requires good preoperative planning and a precise surgical plan, and ultimately prostheses are fabricated in consideration of function and soft-tissue support.^4,5,6 Pre planning of the prosthesis is an important criteria to achieve desired end results. Since the use of fixed partial dentures necessitates the destruction of adjacent teeth to prepare them as abutments and loss of valuable tooth structure it is not a great choice especially in young patients. Removable partial dentures leads to the loss of alveolar bone on both abutment and non-abutment teeth. Moreover the dissatisfaction rate of removable partial dentures is also relatively high.

CONCLUSION

It becomes imperative to do proper planning, precisely place the implants and handle the soft tissue delicately if the anterior teeth need to be restored successfully with implants. Timing of placement, subcrestal positioning, and choice of implant system are also important to get it right in the esthetic zone.

REFERENCES